Recent landmark studies have demonstrated the effectiveness of STN and GPi DBS for appropriate Parkinson disease patients.
[82] In a randomized, controlled trial of 255 patients enrolled in the Veterans Affairs (VA) Cooperative Studies Program (CSP) trial for patients with advanced Parkinson disease, bilateral DBS (STN and GPi) was more effective than best medical therapy in improving on time without troublesome dyskinesia, motor function, and quality of life at 6 months; however, DBS was associated with an increased risk of serious adverse events.
[83] In the same study, when the 2-year outcomes of 147 patients who received STN DBS and 152 patients who received GPi DBS were compared, motor function and adverse events were not significantly different between the 2 sites.
[84] However, those who received STN DBS had a greater reduction in dopaminergic medications, and individuals who received GPi DBS had significantly less depression.
[84]

Investigators from the EARLYSTIM Study Group reported that relative to medical therapy alone, STN DBS in conjunction with medical therapy offers benefits earlier in the course of PD, before the appearance of severe disabling motor complications.
[85, 86] Moreover, subthalamic stimulation plus medical therapy was superior to medical therapy alone on several key measures of quality of life and motor function. However, 54.8% of the patients in the DBS group suffered serious adverse events, compared to 44.1% of those in the medical-therapy group
[85, 86] ; 17.7% of patients suffered serious adverse events related to surgical implantation or the neurostimulation device.

National Collaborating Centre for Chronic Conditions. Parkinson's disease: National clinical guideline for diagnosis and management in primary and secondary care. London, UK: Royal College of Physicians; 2006.

Parkinson disease diary. The patient or caregiver should place 1 check mark in each half-hour time slot to indicate the patient's predominant response during most of that period. The goal of therapeutic management is to minimize off time and on time with troublesome dyskinesia. Copyright Robert Hauser, 1996. Used with permission.

Sagittal section, 12 mm lateral of the midline, demonstrating the subthalamic nucleus (STN) (lavender). The STN is one of the preferred surgical targets for deep brain stimulation to treat symptoms of advanced Parkinson disease.

The deep brain stimulating lead is equipped with 4 electrode contacts, each of which may be used, alone or in combination, for therapeutic stimulation.

Axial, fast spin-echo inversion recovery magnetic resonance image at the level of the posterior commissure. The typical target for placing a thalamic stimulator is demonstrated (cross-hairs).

Implantation of the deep brain stimulation (DBS) lead.

Insertion of an electrode during deep brain stimulation for Parkinson disease.

Radiograph of the skull depicting a deep brain stimulator and leads in a patient with Parkinson disease.

Lewy bodies in the locus coeruleus from a patient with Parkinson disease.

A: Schematic initial progression of Lewy body deposits in the first stages of Parkinson disease (PD), as proposed by Braak and colleagues. B: Localization of the cluster of significant volume reduction in PD compared with health control subjects. The significant cluster located in the medulla oblongata/pons is superimposed as a red blob on the mean normalized anatomic scan of all participants. The axial and sagittal sections are centered on the peak of significance (–1; –36; –49). This image using voxel-based morphometry (VBM), which searched for regional atrophy in idiopathic PD by comparing a group of subjects with the disease and a group of healthy controls. Jubault T, Brambati SM, Degroot C, et al. Regional brain stem atrophy in idiopathic Parkinson's disease detected by anatomical MRI. PLoS ONE. 2009;4(12):e8247.

Gross comparison of the appearance of the substantia nigra between a normal brain and a brain affected by Parkinson disease. Note the well-pigmented substantia nigra in the normal brain specimen on the left. In the brain of a Parkinson disease patient on the right, loss of pigmented substantia nigra due to depopulation of pigmented neurons is observed.

Lewy bodies are intracytoplasmic eosinophilic inclusions, often with halos, that are easily seen in pigmented neurons, as shown in this histologic slide. They contain polymerized alpha-synuclein; therefore, Parkinson disease is a synucleinopathy.

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Tables

Contributor Information and Disclosures

Author

Robert A Hauser, MD, MBA Professor of Neurology, Molecular Pharmacology and Physiology, Director, USF Parkinson's Disease and Movement Disorders Center, National Parkinson Foundation Center of Excellence, Byrd Institute, Clinical Chair, Signature Interdisciplinary Program in Neuroscience, University of South Florida College of Medicine

Disclosure: Received consulting fee from Cerecor for consulting; Received consulting fee from L&M Healthcare for consulting; Received consulting fee from Cleveland Clinic for consulting; Received consulting fee from Heptares for consulting; Received consulting fee from Gerrson Lehrman Group for consulting; Received consulting fee from Indus for consulting; Received consulting fee from University of Houston for consulting; Received consulting fee from AbbVie for consulting; Received consulting fee from Adama.

Coauthor(s)

Kelly E Lyons, PhD Research Professor of Neurology, Director of Research and Education, Parkinson’s Disease and Movement Disorder Center, University of Kansas Medical Center

Disclosure: Received honoraria from Novartis for speaking and teaching; Received honoraria from Teva Neuroscience for speaking and teaching; Received honoraria from St Jude Medical for board membership.

Theresa A McClain, RN, MSN, ARNP-BC Advanced Registered Nurse Practitioner and Investigator, Parkinson’s Disease and Movement Disorders Center, University of South Florida College of Medicine

Disclosure: Received consulting fee from Teva for consulting; Received consulting fee from Schering Plough for consulting; Received consulting fee from Biotie for consulting; Received consulting fee from Novartis for consulting.

Thomas L Carroll, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Tufts University School of Medicine and Director, The Center for Voice and Swallowing, Tufts Medical Center